A quality assurance program for image quality of cone-beam CT guidance in radiation therapy

The clinical introduction of volumetric x-ray image-guided radiotherapy systems necessitates formal commissioning of the hardware and image-guided processes to be used and drafts quality assurance (QA) for both hardware and processes. Satisfying both requirements provides confidence on the system's ability to manage geometric variations in patient setup and internal organ motion. As these systems become a routine clinical modality, the authors present data from their QA program tracking the image quality performance of ten volumetric systems over a period of 3 years. These data are subsequently used to establish evidence-based tolerances for a QA program. The volumetric imaging systems used in this work combines a linear accelerator with conventional x-ray tube and an amorphous silicon flat-panel detector mounted orthogonally from the accelerator central beam axis, in a cone-beam computed tomography (CBCT) configuration. In the spirit of the AAPM Report No. 74, the present work presents the image quality portion of their QA program; the aspects of the QA protocol addressing imaging geometry have been presented elsewhere. Specifically, the authors are presenting data demonstrating the high linearity of CT numbers, the uniformity of axial reconstructions, and the high contrast spatial resolution of ten CBCT systems (1-2 mm) from two commercial vendors. They are also presenting data accumulated over the period of several months demonstrating the long-term stability of the flat-panel detector and of the distances measured on reconstructed volumetric images. Their tests demonstrate that each specific CBCT system has unique performance. In addition, scattered x rays are shown to influence the imaging performance in terms of spatial resolution, axial reconstruction uniformity, and the linearity of CT numbers.